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Captain Niels Tangherlini, right, stops to talk with James Pond, left, and Eddie Giberson. Tangherlini often has to transfer Pond to a medical facility and is talking to him about medical services available.
Niels Tangherlini is a captain with the San Francisco Fire department and a paramedic. He drives a van stopping to help the homeless and those with chronic medical conditions get the medical help they need. He also steers people toward services and is an acknowledged good will ambassador on the streets of San Francisco.
{By Brant Ward/San Francisco Chronicle}12/13/07

Niels Tangherlini is willing to state the hard truths about San Francisco's street population. And he's doing it, even if it causes howls of protests from advocates for homeless people or from some city political leaders.

For example, Tangherlini strongly believes some severely mentally ill street people need "long-term, regular care. And if they don't want to accept that, we may have to impinge on their civil rights."

He also believes that, in some cases, just giving someone a room isn't the answer either.

"We hear that all the time," Tangherlini says. " 'All they need is housing.' I don't want to get into a war with the advocates, but I strongly disagree. We get some of these guys into supportive housing and they can't handle it."

And most of all, Tangherlini thinks that the current system of support, where a 911 call sends an ambulance rushing out to treat someone who is likely to be a "chronic inebriant," is an ongoing disaster. Some of those who call clearly need medical care, but many are using the ambulance and the Fire Department as a personal taxi to the emergency room. He says it is stressing the system, the care providers and the city's financial well-being.

So who is Tangherlini, and how can he say these things?

On one hand, Tangherlini is a local success story. A paramedic with the Fire Department, Tangherlini went back to school for a degree in social work, then pitched the city on his idea that, instead of an ambulance and fire truck, "what a lot of these people need is a van with a paramedic and a social worker."

Tangherlini got his van in 2004 and now works with thousands of people on the street, often with a social worker in the passenger seat next to him. He is pushing them into treatment programs, following up on people at risk, and - in what he thinks is his most worthwhile achievement - sometimes arriving at 911 calls in time to call off both the ambulance and fire rescue crew because he knows the callers well and can get them help without a trip to the overcrowded emergency room.

Sounds great, doesn't it? A Chronicle story in 2005 praised Tangherlini's efforts and noted that between March 2004 and August 2005, a relatively small group of people - just 362 individuals - accounted for 3,869 ambulance trips to the hospital. The story estimated that at roughly $3,000 per pickup and visit to the ER, the cost to the city could be over $11 million.

The bad news is, despite Tangherlini's undeniable good work, the system is still stretched to the breaking point.

But she then gestured around the crowded ER, where rolling beds with dozing patients lined the halls. Despite the efforts, "chronic inebriants" are still a huge problem.

"I see the abuse" of the emergency medical services, said Chavez, who estimated that on some nights, 70 percent of the beds are filled with chronic drinkers who are repeat visitors. "We don't have that much room here. We need to take care of the sick and wounded."

Spending a day with Tangherlini gives a sense of the scale of the problem. For example, during a nonstop day of calls, he visited a Sixth Street hotel where an extremely intoxicated occupant had already been placed in an ambulance. Tangherlini was familiar with the man, who lay on a stretcher in the back of the unit, awake but unresponsive.

"You know that you are at risk of losing this housing," Tangherlini said, looking into the man's eyes. "Does that worry you?"

There was no reaction.

"He's been telling me it is February of 1967," the ambulance technician said.

The man is a "frequent flier," the term used by public health officials all over the country for someone who routinely uses ambulance and ER services. Tangherlini says the man took 21 ambulance rides in the previous month and was just released from the hospital two days earlier.

"We've given him supportive housing," he says. "We've given him a caseworker. He's gotten both barrels of community-based care. It isn't working. This is the population that will break your emergency system. There is no more inefficient way to detox someone than to do it in the hospital."

In a perfect world, Tangherlini would like an expanded, well-funded, stand-alone detox center. A step in that direction is the Department of Public Heath's "sobering center" on Fell Street, which was established in 2003. Chronic inebriants who are not facing a life-threatening condition can be taken there instead of to the emergency room.

Tangherlini is a regular at the sobering center. Last week, he was working with the sort of client he calls "a death mission alcoholic." The man, only 30, had been sober, doing well, even talking about getting a job.

But when he fell off the wagon, he fell hard. He's lost his housing and is drinking again, and Shannon Smith, a nurse at the sobering center, said that on the day we saw him, he was on the verge of an alcohol-induced seizure. Tangherlini and Smith knew the man well, and had obviously built up a bond of trust.

"They come in, they leave, and they come back in an ambulance," says Smith. "The problem is the days when Niels is off."

What the program could really use is more paid staffers with Tangherlini's qualifications. Four more would provide 24-hour service. Those who are out working the streets for a better San Francisco can't understand the bickering over policy.

"We've got to stop making this a battle line between the advocates and the providers," Tangherlini said. "As paramedics, we are the ones working with these people. And we are the ones declaring them dead in the gutter."